Pelvic Organ Prolapse

History

Fact

Explanation

Lump at the introitus

Prolapse is the abnormal protrusion of a whole or part of a structure beyond its normal confines. Pelvic organ prolapse (POP) in a female are described in relation to vaginal walls. Cystocele, urethrocele and cystourethrocele are classified as anterior vaginal wall prolapse. Rectocele and enterocele appear from the posterior vaginal wall while uterovaginal prolapse and vault prolapse is classified as apical vaginal prolapse.[1]

Local discomfort

Prolapse confined within the vagina may be asymptomatic or present with minor non-specific symptoms. The patient may have pain during sexual intercourse (superficial dyspareunia).

Backache

Due to stretching of the utero-sacral ligaments.

Bleeding

Prolapsed structures are prone to trauma and may ulcerate leading to bleeding from the surface. Infection may further complicate.

Due to the anatomical change associated with cystourethrocele. The misaligned urethra may predispose to stress incontinence. Rarely ureteral kinking may develop due to a large prolapse which may lead to renal failure if persists.

Frequent urinary tract infections

Prolapse of the bladder and urethra increases the chances of pathogenic organisms ascending the urinary tract.

Incomplete bowel emptying, anal incontinence

Due to rectocele. Digitation is the use of fingers to evacuate faecal matter from the prolapsed area.

Assess for risk factors for development of POP

Risk factors could be congenital or acquired. In a majority no specific aetiological agent is found. Congenital causes include congenital connective tissue disorders which are rare. Vaginal delivery is a clear risk factor.[2] Vaginal delivery is associated with ischemic and mechanical damage to nerves, fascia and muscles of the pelvic floor. Pelvic support is weakened with advancing age. Hormonal changes during pregnancy also weaken the pelvic floor. Chronic cough, constipation, straining at micturition etc increase the intra-abdominal pressure leading to added strain on the pelvic floor. Surgery involving the pelvis may lead to intra-operative damage to the pelvic floor structures which in the long term predisposing to POP.[3]

Examination

Exclude abdominal mass and ascites which are risk factors for pelvic organ prolapse.[1]

Vaginal examination : inspect surface of prolapse

Inspect for ulceration, bleeding and features of infection.

Vaginal examination : passage of urine when coughing

Ask patient to cough and observe for stress incontinence.

Vaginal examination : Determine grade of prolapse

A prolapse confined within the vagina is grade 1 uterovaginal prolapse. Grade 2 and 3 are differentiated by the position of the uterine fundus. If the examiner can get above the prolapse and hence above the fundus it is grade 3. If not it is grade 2 and the fundus is within the vagina.

Vaginal examination : examine for presence of rectocele

Observe the posterior aspect of the prolapsed mass. A palpable bulge will be present on the posterior wall when applied pressure to the posterior vaginal wall following reduction.[2]

Vaginal examination : examine for presence of cystourethrocele

Observe for prominent anterior bulging. Anterior rugae is a feature of cystourethrocele. As in rectocele examination a palpable bulge will be felt in the anterior vaginal wall.[2]

Perform rest of vaginal examination

Complete the rest of vaginal examination. Examine for a pelvic mass.

Vaginal examination for the presence of an enterocele

The patient is positioned in the left lateral position and the prolapsed mass is reduced. Introduce the Sim’s speculum and retract the posterior vaginal wall. A sponge forceps is introduced into the vagina and the cervix is displaced anteriorly. Inspect for the presence of a protrusion in the posterior fornix. This may be made more prominent by asking the patient to cough.

Differential Diagnoses

Fact

Explanation

Hypertrophic elongation of cervix

The normal length of the cervix is 2.5cm. Elongation may occur in both the supravaginal andd vaginal part. elongation of the supravaginal part is usually due to prolapse. The actual length of the cervix is normal and depth of fornices is normal. Elongation of the vaginal part is usually congenital. The cervical length is increased and the depth of the fornices is increased. Chronic cervicitis rarely may cause elongation of the cervix. Differentiation between prolapse and elongated cervix is based on clinical findings.[1] The examining fingers can be introduced between the cervix and vaginal wall as opposed to in examination of the uterovaginal prolapse. Cystourethrocele and rectocele is absent.

Chronic uterine inversion

Inversion of the uterus is characterized by protrusion of the fundus through the cervix due to inside out turning of the uterus. The condition may be acute or chronic. Uterine inversion is usually due to mismanagement during labor where excess pressure is applied on the unseparated placenta by pulling on the umbilical cord. Uterine fibroids may rarely predispose to uterine inversion.[2] Protrusion of the uterine fundus through the introitus may mimic uterine prolapse. The patient may present with a lump at the introitus which may cause local discomfort. Per vaginal bleeding may be seen rarely. The bladder and rectum is not associated with the prolapse. Diagnosis is clinical by vaginal examination.

Urethral diverticulum

The distal urethra may protrude through the anterior vaginal wall forming a urethral diverticulum. This is secondary to obstruction of the periurethral glands. The condition may mimic a cystourethrocele. The patient presents with urinary symptoms such as dysuria, frequency and urgency. The diagnosis of the condition is made on physical examination. Urethroscopy or urethrogram may be required. Rarely MRI may be required in diagnostic difficulty and MRI is an accurate diagnostic investigation.[3] Treatment consists of surgical excision.

Dermoid vaginal cyst

Dermoid cyst of the vagina may be acquired or congenital and is usually seen the anterior vaginal wall. It may mimic cystourethrocele.

Investigations - for Diagnosis

The diagnosis is usually clinical. Involvement of the bladder, urethra and bowel can be determined clinically.

Pelvic ultrasound scan

Indicated if pelvic mass is suspected.

Midstream urine for microscopy and culture

Exclude urinary tract infection if urinary symptoms are present.[1]

Urodynamic studies

May be indicated to exclude any detrusor instability prior to surgical repair. Urinary symptoms alone is insufficient to exclude stress incontinence and voiding dysfunction.[2] Inadvertent surgery is associated with worsening of urinary incontinence.

References

Management - General Measures

Fact

Explanation

Patient education

Provide information to the patient regarding the natural course of the disease, aetiology, complications and treatment modalities available. Provide adequate information about each treatment method and their complications. The most appropriate treatment method should be decided with involvement of the patient as well.

Treatment of predisposing factors

If the patient is found to have a treatable aetiological factor – chronic cough, constipation etc appropriate treatment measures should be taken. Failure to do so carries the risk of recurrence.[1]

Management - Specific Treatments

Fact

Explanation

Treatment options

Treatment options available include observation, conservative treatment and surgical treatment. The appropriate option needs to be selected according to severity of symptoms, grade of prolapse and patient wishes.

Conservative treatment

Pelvic floor physiotherapy can be used with patients with minimal symptoms. Pelvic floor exercises aim at improving the strength of the weakened pelvic floor structures.[1] Bowel movement retraining and advice on correct posture help reduce the straining on the pelvic floor. Pessaries are the first line conservative treatment option. Silicone based ring pessary and Gellhorn pessary are the commonly used varieties.[2] A variety of new pessaries are available - Incontinence ring, Inflatoball, Donut, Risser etc. Indications for pessary treatment : as a therapeutic trial, during and after pregnancy, while awaiting surgery and if fertility is desired. Pessaries are replaced periodically to prevent complications. Early complications of pessary treatment are vaginal trauma and pessary failure, late complications include local infection and if left for longer durations incarceration.

Surgical treatment

Surgery aims at restoring the anatomy. Patients who have completed their families may opt for removal of the uterus. Surgery may be carried out by vaginal, abdominal or laparoscopic approaches.

Management of uterine prolapse : Conservative measures

Pelvic floor exercise and ring/ shelf pessaries can be used.

Management of uterine prolapse : Surgical measures

Patients who desire preserving fertility can be treated with Manchester repair, Le Fort colpocleisis and hysterosacropexy.[3] In Manchester repair the cervix is accessed vaginally and the cervix is amputated. This procedure is associated with significant complications due to cervical incompetence and cervical stenosis. In Le Fort colpocleisis the vagina is partially closed without excision of the uterus. It is used in elderly patients who are unfit for major surgery. Patients who have completed their families or patients with troublesome symptoms can be treated with vaginal hysterectomy. An incision is made around the cervix to access the uterus and surgeon ascends further by ligating the major blood vessels. The uterus is delivered vaginally and the vault is repaired. The uterosacral ligaments are sutured to the repaired vault of the vagina to improve support. Vaginal hysterectomy combined with anterior and posterior colporrhaphy is the standard the surgical procedure for procidentia with cystocele and rectocele.[4]

Management of cystourethrocele

Cystourethrocele causing minimal symptoms can be managed conservatively with pelvic floor exercises and pessary treatment. Surgical repair aims at restoring the anatomy and Anterior colporrhaphy is the preferred surgical procedure.[5] An incision is made on the anterior vaginal wall and the defect causing the bladder to protrude is identified. The bladder is reduced and the fascial defect is closed. Excess vaginal epithelium is excised.

Management of rectocele/ enterocele

Rectocele can be managed conservatively with pelvic floor physiotherapy and pessaries. The definitive treatment for rectocele is posterior colporrhaphy.[5] An incision made in the posterior vaginal wall is used to identify the fascial defect which is then repaired after restoring the position of the rectum. Excess vaginal epithelium is excised. A similar procedure is used for surgical repair of an enterocele. The peritoneal sac containing the herniated bowel is excised and the pouch of Douglas is closed by approximation of the peritoneum and uterosacral ligaments.

Vaginal Vault Prolapse (Green-top 46). Royal College of Obstetricians and Gynaecologists, 2007 [viewed on 22 July 2014]. Available from : http://www.rcog.org.uk/womens-health/clinical-guidance/management-post-hysterectomy-vaginal-vault-prolapse-green-top-46